Survey of Health Insurance Marketplace Assister Programs

The Affordable Care Act (ACA) provides for a substantial new infrastructure of consumer assistance in health insurance. All state Marketplaces are required to have Navigators and other similar Assister Programs to help consumers understand their coverage options, apply for assistance, and enroll. In addition, comprehensive State Ombudsman or Consumer Assistance Programs (CAPs) are established under the ACA to provide a full range of help – outreach and enrollment assistance as well as help with post-enrollment problems such as appealing denied claims – to all state residents in all types of group and non-group health plan coverage. Throughout the first Open Enrollment period, public attention focused on the number of people who would enroll in qualified health plans (QHPs) offered through the Marketplace and in Medicaid. People will continue to enroll in coverage throughout the year, and even more people are projected to enroll next year, but the close of Open Enrollment affords an opportunity to examine the role of Assister Programs in helping people to enroll and remain enrolled in coverage.

This report is based on findings from the 2014 Kaiser Family Foundation survey of Health Insurance Marketplace Assister Programs. This internet survey was conducted from April 24 to May 12, 2014, shortly after the first Open Enrollment period concluded. Federal and state-operated Marketplaces provided email contact information for directors of their Assister Programs, all of whom were invited to participate. This report examines the experience of Assister Programs across the states in conducting outreach and enrollment assistance during the first Open Enrollment period for health insurance Marketplaces established by the ACA. Based on responses to this survey extrapolated to the total number of Assister Programs, this report offers the first nationwide assessment of the number and type of Assister Programs and the number of people they helped. This report also examines the nature of help consumers needed, both pre- and post-enrollment, and the extent to which Assister Programs could meet consumer needs. In addition, it discusses key factors that impacted the effectiveness of Assister Programs at the outset and the outlook for consumer assistance in the future.

More than 4,400 Assister Programs, employing more than 28,000 full-time-equivalent staff and volunteers, helped an estimated 10.6 million people during the first Open Enrollment period.

Assistance resources were not evenly distributed across states. In states with State-based Marketplaces (SBM) and Consumer Assistance Partnership Marketplaces (FPM), there were about twice as many Assisters available per 10,000 uninsured, compared to states with a Federally-facilitated Marketplace (FFM). The number of people helped per 1,000 uninsured was also greater in State and Partnership Marketplaces; SBMs helped about twice as many people relative to the uninsured population compared to FFMs, while FPMs helped about 1.5 times as many relative to the uninsured population. Some people who were helped enrolled in new QHPs, and some in Medicaid and CHIP. Others who sought help didn’t enroll in coverage, for example, if they were ineligible for both Medicaid and premium tax credits.

During the first year more than 70% of Assister Programs were supported privately or by a federal safety net clinic program.

Under the ACA, Marketplaces are required to support consumer assistance through operating revenue. All Marketplaces did directly support Assister Programs in 2013-2014, but of all Assister Programs established in the first year, most were funded by sources other than Marketplaces. Certified Application Counselors (CAC) Programs, which generally receive no Marketplace funding, and Programs sponsored by federal health centers funded by grants from the Health Resources and Services Administration (HRSA) together account for 71% of all Assister Programs and account for more than 60% of people who received help.

Overwhelmingly, Assister Programs report people sought help because they simply do not understand the ACA or health insurance and lacked confidence to apply on their own.

Many consumers in search of health insurance sought a more human touch to find their way through the enrollment process. Over 80% of Assister Programs report most or nearly all consumers who sought help didn’t understand the ACA or the coverage choices offered them or simply lacked confidence to apply on their own. Almost 90% of Programs report the majority of consumers they helped were uninsured. Almost three-quarters of Programs say most consumers who sought help struggled to understand even basic health insurance terms such as “deductible” or “network service.” Balky web sites also drove consumers to Assister Programs, as did the application process itself, which can require understanding of the tax code, immigration rules, or family law, depending on a person’s circumstances. Also, because most Marketplaces have not yet completed the single streamlined application that determines eligibility for all forms of subsidized coverage, many consumers sought help obtaining Medicaid eligibility determinations.

Helping consumers was not always an efficient process and took a significant amount of time per case.

Sixty-four percent of Assister Programs reported spending between one and two hours helping each consumer, on average. Explaining rules and options to people with limited understanding of the ACA and health insurance took time. So did waits on hold with Marketplace call centers and frozen computer screens. Programs also report that often consumer questions about health plans couldn’t be easily answered by information posted on Marketplace web sites.

Ninety percent of Assister Programs have already been re-contacted by consumers with post-enrollment questions and problems.

Post-enrollment problems range from consumers not having received their insurance card, to not understanding how to use new health insurance or how to appeal a denied claim. Most Marketplace Assisters are not trained to help consumers appeal denied claims or resolve problems with insurers. Instead, they are supposed to refer consumers to state ombudsman or CAPs, also established by the ACA. CAPs are funded by federal grants, though the last grants were awarded in 2012 and, as a result, some CAPs have stopped providing services and some others are operating at reduced levels. Many Marketplace Assister Programs appear to be unfamiliar with CAPs, even where they are still operating. When Assister Programs encounter post-enrollment problems they can’t help with, they mostly refer consumers to the Marketplace call center or back to their health plan.

Assister Programs believe some key changes could help them work more effectively.

Assister Programs that collaborated with others reported this coordination to be very helpful, though more than half of Assister Programs seldom or never coordinated with other Programs. When coordination did take place, it was most often initiated by Assister Programs themselves or facilitated by outside groups, less often by the Marketplaces. Programs report coordination was useful for directing consumers to the nearest Program with available appointments, in strategic planning of enrollment and outreach events, in sharing specialized staff (such as those who could provide interpreter services), and in troubleshooting and problem solving on complex cases. Some State-based Marketplaces also made dedicated call centers for Assisters, and built Assister portals into their online application system so that Programs could track clients’ status. Programs reported that these features also helped them to work more efficiently.

Three-quarters of Assister Programs say it is very likely they will continue to provide Marketplace assistance next year.

Prior to the first Open Enrollment, 30% of Assister Programs had no prior experience helping consumers and just 16% had experience helping consumers enroll in private health plans. Because so many Assister Programs expect to continue operating next year, the level of experience will likely increase going forward. If Marketplaces continue to invest in resources to support Assister Programs, there could develop a profession of expert Assisters who understand consumer needs and how ACA rules and coverage options apply to them.

Assister Programs will likely play a key role in determining how much enrollment grows in 2015.

The Congressional Budget Office has projected that 13 million people could enroll in Marketplace health plans in 2015, 5 million more than signed up during the first Open Enrollment period. Increasing enrollment will first require maintaining coverage for current enrollees. Many people may need help re-applying for coverage or subsidies. Others with post-enrollment problems may need help resolving them in order to decide if coverage is worth maintaining. Some Assister Programs were already stretched to capacity in 2014. For the first Open Enrollment period overall, most Programs could help most of the people who sought help most of the time. Close to 40% of Programs, though, said they could not help all who sought assistance, with 12% saying demand far outpaced capacity. During the final weeks of Open Enrollment almost half of Assister Programs had to turn away at least some consumers.

Enrolling millions of new consumers also presents challenges. Public understanding of the ACA remains limited. If the first wave of enrollment in 2014 was comprised of those consumers who were the most resourceful and motivated to seek coverage, then investment in consumer assistance will be all the more key in the year to come.

About the Assister Programs Described in this Report

Several types of Assister Programs provide outreach and enrollment assistance to individuals, families, and small businesses seeking to obtain health insurance coverage through new Health Insurance Marketplaces and through the Medicaid expansion available in some states. In this report, we use the following terms to describe different types of Assister Programs.

Navigator refers to Assister Programs that contract directly with the U.S. Centers for Medicare & Medicaid Services (CMS) to provide free outreach and enrollment assistance services to consumers in FFM and in FPM states.1,2 Under the ACA, Navigators must conduct public education and outreach, help consumers apply for subsidies, facilitate enrollment in qualified health plans (QHP), and provide consumers with fair and impartial information about their QHP options. In addition, Navigators must refer consumers to applicable state ombudsman or Consumer Assistance Programs (CAPs) for help with any grievance, complaint or question about coverage once enrolled. Navigators must complete 20-30 hours of federal training to become certified; in some states additional state training requirements apply. CMS also requires Navigators in FFM and FPM states to periodically report data on their activities and performance. Under the ACA, Navigators must be funded by grants from Marketplace operating revenue. However, because there was no operating revenue as of the first Open Enrollment period, CMS funded Navigators out of their pool of other implementation funds. For Fiscal Year 2014, CMS awarded $67 million in federal grants to federal Navigators in 34 states (29 FFM and 5 FPM states).

In Person Assister (IPA) refers to Assister Programs that contract directly with SBMs or FPMs to provide free outreach and enrollment assistance. The duties and standards for IPAs generally mirror those of Navigators. This category of Assister Program was created through federal regulations to allow SBMs and FPMs to use federal exchange establishment grants to fund Assistance Programs.3 In later years, these Marketplaces, like all others, will be required to fund Navigator Programs out of Marketplace operating revenue. Unlike Navigators, which operate under a standard set of rules across states, there is more variation in the size, structure, and functions of IPA Programs. In some states, IPAs are paid on a per-enrollment basis, while in other states they are funded through grants. Additionally, in some states IPAs provide both outreach and enrollment assistance while in other states their primary responsibility is enrollment assistance. In some states, IPA Programs are also called Navigators; however, for purposes of this report, they are categorized as IPAs. For Fiscal Year 2014, 17 SBM and 5 FPM states together allocated over $100 million for their IPA Programs.

Certified Application Counselor (CAC) refers to an Assister Program that is recognized by a Marketplace as a trained Assister but that does not receive direct funding from a Marketplace. CACs also must provide assistance to consumers free of charge. Under federal rules, the duties of CACs are less extensive than that of Navigators or IPAs. In particular, CACs are not required to engage in outreach, though many do. Training requirements for CACs are also less extensive than for Navigators or IPAs. States have flexibility to require additional standards for CACs. CAC Programs must register with the Marketplace and must ensure that their individual Assisters follow applicable standards. Although not funded by the Marketplaces, many CAC Programs received funding from outside sources.

Federally Qualified Health Center (FQHC) refers to Assister Programs operated by health centers that receive federal funding to provide comprehensive primary care services. These health centers have a mission to treat anyone regardless of their ability to pay; as a result, their patients are primarily low-income and many are uninsured. Health centers also have a long history of helping patients apply for Medicaid, the Children’s Health Insurance Program (CHIP), or other coverage. In July 2013, HRSA awarded $150 million to 1,159 health centers in every state and DC to facilitate enrollment of uninsured people into new coverage options available under the ACA. In December 2013, HRSA awarded an additional $58 million in one-time funding to support the anticipated surge in demand for enrollment assistance. In addition, HRSA awarded $6.4 million to state and regional Primary Care Associations (PCA) to provide technical assistance and other support to FQHC Assister Programs. Some FQHC Assister Programs also applied to be Navigators or IPAs and received additional direct funding from Marketplaces. For purposes of this report, all FQHCs are categorized as FQHC Assister Programs even if they also served as Navigators or IPAs.

Federal Enrollment Assistance Program (FEAP) refers to Assister Programs that contracted with CMS to provide supplemental enrollment assistance services within FFM and FPM states in select communities with large numbers of uninsured. Duties and requirements of FEAPs are similar to those of federal Navigators, except that FEAPs provide “surge” assistance. Most have rolled back staff and operations since Open Enrollment ended. In the fall of 2013, CMS awarded contracts totaling $37.5 million to two organizations to establish FEAPs in 13 states.4 FEAP contracts were for one year, with an option for CMS to elect a second year of work by the end of July 2014.

In addition to Marketplace Assister Programs, the ACA authorized creation of state-based ombudsman programs, also called Consumer Assistance Programs, or CAPs. CAPs offer eligibility and enrollment assistance to all state residents, those seeking to enroll through Marketplaces as well as people covered under large employer plans and other non-Marketplace coverage. CAPs also help consumers resolve questions and problems with health coverage once they are enrolled – including appealing denied claims on consumers’ behalf – and health plans must include notice about CAP help on all explanation of benefit (EOB) statements. Under the ACA, Navigators and other Marketplace Assister Programs are required to refer consumers to CAPs for help with such post-enrollment problems. Thirty-five state CAPs were established with federal grants in 2010. Subsequent funding awards were made in 2011 and 2012, but none since. Many CAPs continue to operate, though some at reduced levels. In addition, some CAPs are working as Navigators, IPAs, and CACs. This report discusses coordination with CAPs by other Assister Programs.